By U. Curtis. Our Lady of Holy Cross College.

The main choices of graft for ACL reconstruction are the patellar tendon autograft buy 260mg extra super avana visa erectile dysfunction doctors raleigh nc, the semitendinosus autograft purchase 260 mg extra super avana fast delivery erectile dysfunction diet, and the central quadri- ceps tendon, allograft of patellar tendon, Achilles tendon, or tibialis anterior tendon, and the synthetic graft. Patellar Tendon Graft The patellar tendon graft was originally described as the gold-standard graft. Shelbourne has pushed the envelope further with the patellar tendon graft. He has recently reported on the harvest of the patellar tendon graft from the opposite knee, with an average return to play of four months postoperative. The advantages of the patellar tendon graft are early bone-to-bone healing at six weeks, consistent size and shape of the graft, and ease of 48 5. The disadvantages are the harvest site morbidity of patellar tendonitis, anterior knee pain, patellofemoral joint tightness with late chondromalacia, late patella fracture, late patellar tendon rupture, loss of range of motion, and injury to the infrapatellar branch of the saphe- nous nerve. Most of the complications are the result of the harvest of the patellar tendon. Patellar Tendon Graft Indications The ideal patient for an ACL reconstruction is the young, elite, com- petitive, pivotal athlete. This is the young athlete who wants to return to sports quickly and is going to be more aggressive in contact sports for a longer period of time. There is no upper age limit for patellar tendon reconstruction, but the younger athlete has more time to commit to knee rehabilitation. If the patellar tendon is the gold standard of grafts, then this is the graft of choice for the professional, or elite, athlete. Finally, the competitive athlete understands the value of the rehabilita- tion program and will not hesitate to spend three hours a day in the gym. The author’s assessment is that 50% of the success is the opera- tion, and 50% is the rehabilitation program. Cyclists, runners, swimmers, canoeists, and kayakers, for example, can function well in their chosen sport without an intact ACL. Athletic Lifestyle This operation should be reserved for the athletic individual. If the nonathlete has giving way symptoms, it is probably the result of a torn meniscus and not a torn ACL. The meniscal pathology can be treated arthroscopically, and the patient can continue with the use of a brace as necessary. Patellar Autograft Disadvantages Harvest Site Morbidity The main disadvantage of the patellar tendon graft is the harvest site morbidity. The problems produced by the harvest are patellar ten- donitis, quadriceps weakness, persistent tendon defect, patellar fracture, patellar tendon rupture, patellofemoral pain syndrome, patellar entrap- Patellar Tendon Graft 49 ment, and arthrofibrosis. Kneeling Pain The most common complaint after patellar tendon harvest is kneeling pain. This reduces the injury to the infrapatellar branch of the saphe- nous nerve. Patellar Tendonitis Pain at the harvest site will interfere with the rehabilitation program. The problem is usually resolved in the first year, but it can prevent some high performance athletes from resuming their sport in that first year. Quadriceps Weakness The quads weakness may be the result of pain and the inability to par- ticipate in a strength program. If significant patellofemoral symptoms develop, the athlete may be unable to exercise the quads. Persistent Tendon Defect If the defect is not closed, there may be a persistent defect in the patel- lar tendon. Patella Entrapment If the defect is closed too tight, the patella may be entrapped, and patel- lar infera may result. This will certainly result in patellofemoral pain, because of an increase in patellofemoral joint compression.

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In modern classifications of gait disorders buy extra super avana 260mg without prescription erectile dysfunction treatment hyderabad, gait apraxia is subsumed into the categories of frontal gait disorder 260 mg extra super avana amex erectile dysfunction pump ratings, frontal disequilibrium, and isolated gait ignition failure. Gait apraxia is an important diagnosis to establish since those afflicted generally respond poorly, if at all, to physiotherapy; moreover, because both patient and therapist often become frustrated because of lack of progress, this form of treatment is often best avoided. Human walking and higher- level gait disorders, particularly in the elderly. Neurology 1993; 43: 268-279 Rossor MN, Tyrrell PJ, Warrington EK, Thompson PD, Marsden CD, Lantos P. Progressive frontal gait disturbance with atypical Alzheimer’s disease and corticobasal degeneration. Journal of Neurology, Neurosurgery and Psychiatry 1999; 67: 345-352 Cross References Apraxia Ganglionopathy - see NEUROPATHY Ganser Phenomenon The Ganser phenomenon consists of giving approximate answers to questions which can at times verge on the absurd (Q: “How many legs does a cow have? This may occur in psychiatric disease, such as depression, schizophrenia, and malingering, and sometimes in neurological disease (head injury, epilepsy). A Ganser syndrome of hallucinations, conver- sion disorder, cognitive disorientation and approximate answers is also described but of uncertain nosology. London: Arnold, 2001: 74-94 Gaping Gaping, or involuntary opening of the mouth, may occur as a focal dystonia of the motor trigeminal nerve, also known as Brueghel syn- drome after that artist’s painting De Gaper (“Yawning man,” ca. Afflicted individuals may also - 134 - Gegenhalten G demonstrate paroxysmal hyperpnea and upbeating nystagmus, sug- gesting a brainstem (possibly pontine) localization of pathology. The condition should be distinguished from other cranial dystonias with blepharospasm (Meige syndrome). Neurology 1996; 46: 1767-1769 Cross References Blepharospasm; Dystonia; Nystagmus Gaze-Evoked Phenomena A variety of symptoms have been reported to be evoked, on occasion, by alteration of the direction of gaze: ● Amaurosis: lesion, usually intraorbital, compressing central retinal artery ● Laughter ● Nystagmus: usually indicative of cerebellar lesion; may occur as a side-effect of medications; also convergence-retraction nystagmus on upgaze in dorsal midbrain (Parinaud’s) syndrome ● Phosphenes: increased mechanosensitivity in demyelinated optic nerve ● Segmental constriction of the pupil (Czarnecki’s sign) following aberrant regeneration of the oculomotor (III) nerve to the iris sphincter ● Tinnitus: may develop after resection of cerebellopontine angle tumors, may be due to abnormal interaction between vestibular and cochlear nuclei ● Vertigo Cross References Leopold NA. Journal of Neurology, Neurosurgery and Psychiatry 1977; 40: 815-817 Gaze Palsy Gaze palsy is a general term for any impairment or limitation in conjugate (yoked) eye movements. Preservation of the vestibulo-ocular reflexes may help dif- ferentiate supranuclear gaze palsies from nuclear/ infranuclear causes. Cross References Locked-in syndrome; Supranuclear gaze palsy; Vestibulo-ocular reflexes Gegenhalten Gegenhalten, or paratonia, or paratonic rigidity, is a resistance to pas- sive movement of a limb when changing its posture or position, which is evident in both flexor and extensor muscles (as in rigidity, but not spasticity), which seems to increase further with attempts to get the patient to relax, such that there is a resistance to any applied movement - 135 - G Gerstmann Syndrome (German: to counter, stand ones ground). However, this is not a form of impaired muscle relaxation akin to myotonia and paramyotonia. For instance, when lifting the legs by placing the hands under the knees, the legs may be held extended at the knees despite encouragement on the part of the examiner for the patient to flex the knees. Gegenhalten is a sign of bilateral frontal lobe dysfunction, espe- cially mesial cortex and superior convexity (premotor cortex, area 6). It is not uncommon in elderly individuals with diffuse frontal lobe cerebrovascular disease. Cross References Frontal release signs; Myotonia; Paramyotonia; Rigidity; Spasticity Gerstmann Syndrome The Gerstmann syndrome, or angular gyrus syndrome, consists of acalculia, agraphia (of central type), finger agnosia, and right-left dis- orientation; there may in addition be alexia and difficulty spelling words but these are not necessary parts of the syndrome. Gerstmann syndrome occurs with lesions of the angular gyrus and supramarginal gyrus in the posterior parietotemporal region of the dominant (usually left) hemisphere, for example infarction in the territory of the middle cerebral artery. All the signs comprising Gerstmann syndrome do fractionate or dissociate, i. Nonetheless the Gerstmann syndrome remains useful for the purposes of clinical localization. Archives of Neurology 1992; 49: 445-447 Mayer E, Martory M-D, Pegna AJ et al. London: Imperial College Press, 2003: 92-94 Cross References Acalculia; Agraphia; Alexia; Finger agnosia; Right-left disorientation Geste Antagoniste Geste antagoniste is a sensory “trick” which alleviates, and is character- istic of, dystonia. Geste antagoniste consists of a tactile or propriocep- tive stimulus, which is learned by the patient, which reduces or eliminates the dystonic posture. For example, touching the chin, face or neck may overcome torticollis (cervical dystonia), and singing may inhibit blepharospasm. They are almost ubiquitous in sufferers of cervical dystonia and have remarkable efficacy. The mechanism is unknown: although afferent feedback from the periphery may be relevant, it is also possible that concurrent motor output to generate the trick movement may be the key element, in which case the term “sensory trick” is a misnomer.

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X Pilot the questionnaire and instructions to check that all can be understood order 260mg extra super avana otc erectile dysfunction specialist doctor. It is a procedure for generating under- standing about the way of life of others buy generic extra super avana 260mg online erectile dysfunction bob. However, as there are many practical ‘how to’ issues involved in the use of participant observation, I am going to discuss it as a re- search method. But as you will see, there are several meth- odological issues which are raised in the following discussion, especially concerning ethics and the personal role of the researcher. Participant observation can be carried out within any community, culture or context which is different to the usual community and/or culture of the researcher. It may be carried out within a remote African tribe or in hospitals, factories, schools, prisons and so on, within your own country. The researcher immerses herself into the community – the action is deliberate and intended to add to knowledge. The researcher participates in the community while obser- ving others within that community, and as such she must 101 102 / PRACTICAL RESEARCH METHODS be a researcher 24 hours a day. In practice most research- ers find that they play more of a role as observer, than they do as a participant. GAINING ACCESS Participant observation, as a research method, cannot work unless you’re able to gain access to the community that you wish to study. Before you spend a lot of time plan- ning your project you need to find out whether you can ob- tain this access. The level of negotiation required will depend upon the community, culture or context. If it is a culture with which you already have a certain amount of familiarity, and vice versa, you should find it easier to gain access. However, if it is a secret or suspicious community, youmayfinditmuchhardertogainaccess. If you do expect to encounter difficulties, one way to over- come this problem is to befriend a member of that com- munity who could act as a gatekeeper and help you to get to know other people. Obviously, it is important to spend time building up the required level of trust before you can expect someone to introduce you into their community. If it is not possible to befriend a member of the community, you may have to approach the person or committee in charge, firstly by letter and then in person. First impressions are important and you need to make sure that you dress and act appropriately within the community. Some people will be suspicious of the motives of a researcher, especially if they’re not familiar with the research process. In the early stages it is better to answer any questions or suspicions directly and honestly rather HOW TO CARRY OUT PARTICIPANT OBSERVATION/ 103 than try to avoid them or shrug them off. ETHICS Because of the nature of participant observation, there tends to be more issues involving ethics and morals to consider. As you intend to become part of a specific group, will you be expected to undertake anything illegal? This could happen with research into drug use or crime syndicates where people may not trust you until you be- come one of them and join in their activities. Would you be prepared to do this and put up with any consequences which could arise as a result of your activities? If the group is suspicious, do you intend to be completely honest about who you are and what you’re doing? How would you deal with any problems which may arise as a conse- quence of your deception? What if your participation within a group causes pro- blems, anxiety or argument amongst other members? Would you be prepared to withdraw and ruin all your hard work for the sake of your informants? Also, there are many personal considerations and dilemmas which you need to think about before undertaking participant obser- vation, as illustrated below: 104 / PRACTICAL RESEARCH METHODS PERSONAL CONSIDERATIONS WHEN ENTERING THE FIELD Some people will not accept you. Are you prepared to spend many months studying others and not indulging in talk about yourself? Some researchers overcome this problem by making sure that they have someone outside the community who they can talk to if they need to.

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